Actions of estradiol on discrete attributes of the luteinizing hormone pulse signal in man. Studies in postmenopausal women treated with pure estradiol.

We assessed the time-dependent impact of estradiol on properties of the luteinizing hormone (LH) pulse signal in 12 hypoestrogenemic postmenopausal volunteers studied basally and after 1, 5, 10, and 30 d of estradiol delivery via an intravaginal Silastic ring. Computerized analysis of the plasma LH time series revealed a significant decrease in LH pulse frequency within 24 h of estrogen treatment, followed by a secondary increase (days 5 and 10), and then a sustained decline (day 30) in LH pulsatility. Estradiol also significantly suppressed incremental and maximal (but not fractional) LH pulse amplitudes in a biphasic manner. In contrast, LH peak duration was invariant until day 30 of estradiol replacement. These observations indicate that the well recognized biphasic actions of estradiol on mean serum LH concentrations can be modeled in relation to specific and time-dependent alterations in LH pulse frequency and amplitude.

Pituitary self-priming actions of gonadotropin-releasing hormone. Kinetics of estradiol's potentiating effects on gonadotropin-releasing hormone-facilitated luteinizing hormone and follicle-stimulating hormone release in healthy postmenopausal women.

We examined the kinetically distinct characteristics of estradiol's effects upon pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release in response to pulses of exogenous gonadotropin-releasing hormone (GnRH) in healthy postmenopausal individuals. The putative self-priming actions of GnRH on LH and FSH release were tested by intravenous injections of equal paired doses of GnRH (10 micrograms) before and after 1, 5, 10, and 30 d of pure estradiol-17 beta delivery via an intravaginal silastic ring. Self-priming actions of GnRH, as defined by heightened gonadotropin release in response to the second pulse of GnRH compared with the first, were completely absent in the hypoestrogenemic state. However, estradiol administration unmasked GnRH self-priming in a time-dependent fashion, with maximal expression after 5 and 10 d of steroid replacement, followed by attenuation by 30 d. Since estradiol's modulation of GnRH action was expressed differentially on LH and FSH release, we suggest that such facilitation of GnRH-stimulated pituitary LH and FSH release may provide an additional mechanism for dissociated secretion of gonadotropic hormones in health or disease.

Fat metabolism in higher plants. Production of short- and medium-chain acyl-acyl carrier protein by spinach stroma preparations treated with cerulenin.

Incubation of stroma preparations from spinach chloroplasts with low concentrations of cerulenin (10 muM) resulted in severe inhibition of fatty acid synthesis but stimulated the release of medium-chain acids in very high proportions (60-70%). Preincubation of these preparations with cerulenin in the absence of substrate exerted no additional effect on subsequent fatty acid synthesis (as measured by incorporation of [14C]acetate into fatty acids) or the pattern of radioactive acids obtained. Acyl-protein, acyl-CoA, free fatty acids and lipids were resolved from each other and analysed for their distribution of 14C-labelled fatty acids. Acyl-protein derived from cerulenin-treated preparations was the only fraction which contained short- and medium-chain acids (C6--C12). The other fractions from both control and cerulenin-treated groups consisted exclusively of C16 and C18 acids. Acyl-protein was purified by gel filtration chromatography and was characterized as acyl-acyl carrier protein.

Development of a vaginal ring for achieving physiologic levels of 17 beta-estradiol in hypoestrogenic women.

The ability of polysiloxane vaginal rings containing 17 beta-Estradiol (E2) to deliver E2 into the systemic circulation at a steady rate over long periods of time was evaluated in castrate and postmenopausal volunteers. Standard laminar designs, used to release contraceptive gestagens, deliver low levels of E2 (about 50 pg/ml) and only for 1 month. With a modified design, E2 levels of 109 to 159 pg/ml were maintained for at least 3 months, and circulating gonadotropins were suppressed to values approaching the premenopausal range. This homogeneous design provides for physiologic replacement of E2 as well as a practical research tool for studying chronic effects of E2 in human subjects.

Changes in physiologically free circulating estradiol and testosterone during exposure to levonorgestrel.

PIP: The biological activity of circulating sex steroids is dependent upon the relative binding to (SHBG) sex hormone-binding globulin. Only that fraction which is not specifically bound to the high affinity binding protein is available to the receptors or for metabolism. (D-Ng) Levonorgestrel, a synthetic gestagen used for contraception decreases the hepatic production of SHBG. Volunteers wearing contraceptive vaginal rings containing (E2) estradiol and d-Ng were studied to determine the changes in sex steroid binding which occur when d-Ng is administered in a sustained release fashion. The % of steroids not specifically bound to SHBG was measured by fractionating the serum proteins with ammonium sulfate precipitation. A binding capacity assay was used to quantitate SHBG. During the normal menstrual cycle in control subjects, the unbound fractions of both E2 and (T) testosterone remained constant at about 25% of total E2 and 10% of total T. During treatment with d-Ng, however, the % of unbound E2 increased to about 80% of the total, and that of T increased to about 55% of the total, significantly greater than that in the control cycles (p 0.01). SHBG was constant during the normal menstrual cycle, averaging 85.9 + or - 1.92 nM but was suppressed during the administration of d-Ng to 10.0 + or - 2.6 nM. When SHBG concentration was greater than 50 nM, the % binding of both E2 and T were independent of the concentration of this binding protein. When SHBG was suppressed below 50 nM, the % binding of E2 and T was directly related to the concentration of the binding protein. The affinity of SHBG for d-Ng allows competition with E2 and T for SHBG-binding sites at concentrations of SHBG below 50 nM. The increase in physiologically free E2 and T, therefore, may be a result of both the suppression of SHBG concentration by d-Ng as well as the competition between d-Ng and endogenous sex steroids for the decreased number of available binding sites on SHBG.^ieng

Endogenous opiates participate in the regulation of pulsatile luteinizing hormone release in an unopposed estrogen milieu: studies in estrogen-replaced, gonadectomized patients with testicular feminization.

Administration of opiate receptor antagonists augmented pulsatile LH release in six estrogen-treated, orchidectomized individuals with testicular feminization. In response to an opiate antagonist, LH pulse frequency increased from 3.0 +/- 0.55 (+/- SE) to 5.0 +/- 0.45 pulses/8 h (P = 0.034). Since these patients have inborn target tissue resistance to androgens, we infer that sustained androgen action is not obligatory to the emergence of endogenous inhibitory opiate tone in man. Rather, these observations document that the suppressive effects of opiates on gonadotropin secretion can be unmasked in the presence of an unopposed estrogen milieu.

Selecting constant serum estradiol levels achieved by vaginal rings.

Prolonged, constant, systemic administration of estradiol-17 beta is useful for research and clinical purposes. Sustained systemic administration of estradiol-17 beta can be accomplished by means of estradiol-17 beta-containing polydimethylsiloxane vaginal rings. The ability to preselect a specific circulating serum level of estradiol-17 beta from several possible levels using estradiol-17 beta vaginal rings would be advantageous. In the present study, the author examined the effects of changes in the surface area and estradiol-17 beta content of estradiol-17 beta vaginal rings on the resulting serum levels of estradiol-17 beta. During three months of estradiol-17 beta vaginal ring exposure, the average serum levels of estradiol-17 beta produced were 53 +/- 10 pg/mL with a 100-mg estradiol-17 beta vaginal ring, 81 +/- 7 pg/mL with a 200-mg estradiol-17 beta vaginal ring, and 152 +/- 14 pg/mL with a 400-mg estradiol-17 beta vaginal ring. When compared with levels of estradiol-17 beta observed in normal menstrual cycles, the levels obtained with the 100-mg estradiol-17 beta vaginal ring, 200-mg estradiol-17 beta vaginal ring, and 400-mg estradiol-17 beta vaginal ring correspond to early follicular phase, midfollicular phase, and complete menstrual cycle, respectively. The author concludes that stable circulating levels of estradiol-17 beta resulting from estradiol-17 beta vaginal ring administration resemble estradiol-17 beta levels characteristic of specific phases of the normal menstrual cycle. Therefore, estradiol-17 beta administration by estradiol-17 beta vaginal ring may be helpful for research and clinical applications.

Increasing occurrence of condylomata acuminata in premenarchal children.

The incidence of condylamata acuminata in adults is reported to be increasing. The presence of this lesion in young children, previously a rare occurrence, is also being seen more frequently. A review of the English-language literature revealed only 19 cases reported since 1940. This report adds 3 new cases to that number, all young premenarchal girls. Since the etiology of this disease is the infectious transmission of a viral agent, it is reasonable to suppose that more children are being exposed to the disease by infected adult family members. Clinicians should be aware of this possibility when treating adults with condylomata acuminata,and when examining children referred to them because of perineal lesions.

Pharmacokinetics of estrogen.

The main types of pharmacologic therapy used to treat the hormone deficiency of menopause are parenteral and oral administrations of estrogen. Parenteral administration results in predictable absorption without major intermediary metabolism, whereas all oral estrogens are subject to intestinal metabolism before entering the systemic circulation. Various options are available. Injectable estrogens, because of rapid absorption and metabolism, are impractical for long-term replacement therapy. The primary drawback to subcutaneous estradiol pellets is the surgical procedure required for their insertion and removal. Vaginal epithelium is an effective pathway for absorption of estrogen given by solution, tablet, or cream, although only the latter is currently approved for clinical use; relatively constant serum levels of estradiol can be obtained with vaginal rings. Transdermal patches provide controlled hormone levels for up to 3.5 days. Although oral conjugated equine estrogens have been used extensively, they introduce types of estrogen, such as equilin, that are not naturally found in humans and that can produce a pronounced hepatic response. Micronized estradiol, oral estrone, and other estrogens have been used as alternatives to equine estrogens. Clinicians should understand the pharmacokinetics of the various options for replacement therapy and select a course of treatment that is safe, effective, and convenient for the patient.

In vitro penetration of human sperm into bovine cervical mucus: effects of sperm washing and exposure to low temperature.

Standardized bovine cervical mucus penetration by human sperm in vitro provides information for evaluating male fertility. Normal semen specimens from 20 sperm donors and 17 infertile men were tested for cervical mucus penetration. Rigorous control of test temperature was necessary to guarantee the reliability and reproducibility of cervical mucus penetration. Sperm washing was found to significantly improve cervical mucus penetration for infertile men, from 18 +/- 2.2 to 27 +/- 3.4 mm, P less than .025. Sperm washing for normal donors had no apparent effect on cervical mucus penetration (58 +/- 1.5 mm prewash, 55 +/- 1.7 mm postwash, P greater than .1). The authors conclude that: 1) temperature for cervical mucus penetration testing is critical to reliability, and 2) cervical mucus penetration is a useful screening tool for in vitro procedures proposed to improve sperm function.

Unilateral twin interstitial ectopic pregnancy. Report of a case.

An unusual case of twin unilateral interstitial pregnancy is described. On admission the patient was thought to have an intrauterine pregnancy of 14 weeks' gestation. Because of an irregularity in the right cornual region of the uterus, a culdocentesis was performed which returned unclotted blood. Because of this finding the patient underwent laparoscopy which revealed an unruptured right cornual pregnancy. An early diagnosis before rupture allowed for conservative surgical management and uterine conservation.

Febrile morbidity following hysterosalpingography: identification of risk factors and recommendations for prophylaxis.

Although previous large series have reported that from 0.3% to 1.3% of patients undergoing hysterosalpingography (HSG) develop infectious morbidity, our impression was that the incidence was higher among our patients. Therefore the records of 448 consecutive healthy women who underwent HSG were examined. Within 24 hours after the HSG, 14 of these 448 patients (3.1%) developed fever and pelvic peritonitis requiring hospitalization and treatment with parenteral antibiotics, a significantly greater frequency than reported elsewhere (P less than 0.01). Traditional laboratory tests failed to predict patients at risk, and prophylactic antibiotics effective against aerobic organisms could not protect against this complication. However, it was possible to design a scoring system based on specific findings in the history and previous physical examinations that was capable of identifying patients who would subsequently become infected. The clinical sensitivity of this scoring technique is 57%, clinical specificity 99%, and test efficiency 97%. It is suggested that in view of the major risk of post-HSG infection in certain identifiable women and because of the impact of this complication on their future fertility, hysterosalpingography should not be performed in those patients determined to be at high risk. In women at lowest risk, the procedure is safe. Finally, in patients assigned an intermediate risk-score, the risk-benefit ratio must be carefully weighed and discussed with the patient, and prophylactic antibiotics with anaerobic coverage should be considered.

Estradiol and progesterone replacement regimens for the induction of endometrial receptivity.

Initiation of pregnancy in premature ovarian failure patients by use of donated oocytes fertilized in vitro requires establishment of a normal endometrial environment. We compared administration of estradiol (E2) and progesterone (P) by polysiloxane vaginal rings versus oral micronized E2 and P vaginal suppositories in 10 such patients. Serum E2 levels were similar between groups and similar to normally-cycling controls. With vaginal administration of E2, a burst effect was noted, with marked elevation 1 hour after insertion. The pattern with oral administration was more consistent, although marked conversion to estrone occurred. The P cylinder and suppositories delivered similar levels, with diminution of P in some patients with the cylinder. Despite apparent limitations, endometrial histology was normal after each cycle; both groups achieved pregnancies. Administration of E2 and P by polysiloxane vaginal rings achieved hormonal levels similar to oral micronized E2 and P vaginal suppositories. Endometrial biopsies after the stimulated cycle were appropriately mature.

Polysiloxane vaginal rings and cylinders for physiologic endometrial priming in functionally agonadal women.

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Women athletes with menstrual irregularity have increased musculoskeletal injuries.

We have performed a retrospective three-phase study to evaluate the effect of menstrual status upon musculoskeletal injuries in women athletes. Initially, we collected the menstrual and running histories of women participants in a regional 10-km footrace. In this study, 61% of the respondents to our questionnaire reported a continuous running program, and 39% reported an interruption of at least 3 months of their running program. The most common cause for interruption was injury. Those who had interrupted their running were more likely to have had irregular or absent menses and less likely to have been using oral contraceptives than the group of continuous runners. Secondly, we obtained information on the relationship between bone injury and menstrual status by reviewing the sports medicine records of 207 collegiate women athletes. We found that X-ray-documented fractures occurred in 9% of women athletes with regular menses and in 24% of women athletes with irregular or absent menses. Subsequently, we collected data from a larger population of more serious, but still recreational runners, participating in a national 10-km race. Each portion of this study has yielded similar results: those women who had been injured during their running program were more likely to have had absent or irregular menses, were less likely to have used oral contraceptives, and had been running for more years. We conclude that premenopausal women who have absent or irregular menses, while engaged in vigorous exercise programs, are at increased risk for musculoskeletal injury.

Results of establishing medical guidelines for selecting oral contraceptive types in family planning agencies.

Family planning agencies are attempting to increase their efficiency and cost-effectiveness in delivering services, as federal funding is diminishing. We have examined the effects of establishing guidelines in a family planning agency, outlining the types of OCs to be routinely prescribed. We found that substantial savings in purchase costs were achieved, in addition to simplified inventory and distribution. These savings were accomplished with no perceptible change in patients' satisfaction. The equivalence of modern OCs in safety and effectiveness allows the creation of guidelines which are medically sound.

PIP: Family planning agencies are attempting to increase their efficiency and cost effectiveness in delivering services as federal funding is diminishing. The authors examined the effects of establishing guidelines in a family planning agency, outlining the types of oral contraceptives (OCs) which can be routinely prescribed. They found that substantial savings in purchase costs were achieved, in addition to simplified inventory and distribution. These savings were accomplished with no perceptible change in patients' satisfaction. The equivalence of modern OCs in safety and effectiveness allows the creation of guidelines which are medically sound.

Insertion technique, not design, affects expulsion rates of postpartum intrauterine device.

A Lippes type intrauterine device (IUD) was modified to be used for immediate postpartum insertion. In 114 patients in whom the modified IUD was inserted immediately after delivery, expulsion rates at six months averaged approximately 30%. Expulsion rates were significantly different, at p less than 0.05, for women in whom the IUD was inserted digitally (19.5 +/- 5.6% at 6 months) compared to those in whom it was inserted using surgical forceps (39.6 +/- 7.1%). Furthermore, expulsion rates were higher for inexperienced inserters (p less than 0.01). We conclude that: 1) this modification of an otherwise standard IUD has a continued high expulsion rate, and 2) the technique of insertion has significant impact upon the likelihood of expulsion.

PIP: A Lippes loop IUD was modified to be used for immediate postpartum insertion. In 114 patients in whom the modified IUD was inserted immedicately after delivery, expulsion rates at 6 months averaged approximately 30%. Expulsion rates were significantly different at P0.05 for women in whom the IUD was inserted digitally (19.5 +or- 5.6% at 6 months) compared to those in whom it was inserted using surgical forceps (39.6 +or- 7.1%). Furthermore, expulsion rates were higher for inexperienced inserters (P0.01). The authors conclude that: 1) this modification of an otherwise standard IUD has a continued high expulsion rate, and 2) the insertion technique has significant impact on the likelihood of expulsion.

Effect of vaginal contraceptive sponges on growth of toxic shock syndrome-associated Staphylococcus aureus in vitro.

Toxic Shock Syndrome (TSS) is associated with certain toxin-producing strains of Staphylococcus aureus (TSS-S aureus), and with the use of some vaginal devices such as tampons or contraceptive diaphragms. The present study was designed to examine the effect of Nonoxynol-9 (N-9), and of a newly-approved vaginal contraceptive sponge (VCS) containing N-9 on the growth of TSS-S aureus in vitro. Flasks containing culture media inoculated with TSS-S aureus were incubated at 37 degrees C for 30 hours, in the presence or absence of either a VCS, or N-9 alone. At 0.5, 1, 2, 6, and 12 hours, there was suppression of TSS-S aureus colony counts in media containing VCS, compared to control. Colony counts from media containing N-9 demonstrated suppression at 0.5, 1, 2, and 6 hours. After incubation as long as 30 hours, colony counts from VCS-containing media approached, but did not exceed, counts from control media. From these data, it is concluded that this VCS containing N-9 does not enhance the growth of TSS-S aureus in vitro. Instead, an inhibition of bacterial growth for at least 12 hours is observed in media containing VCS, consistent with a bacteriostatic effect. If such an effect is also present in vivo, it would suggest that this type of VCS is unlikely to increase the risk of TSS.